review of mi inpromoting health behaviors
TRANSCRIPT
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Review of Motivational Interviewing in promoting health behaviors☆,☆☆
Renata K. Martins ⁎, Daniel W. McNeil ⁎
West Virginia University, 53 Campus Drive, P.O. Box 6040, Morgantown, West Virginia 26506-6040 USA
a b s t r a c ta r t i c l e i n f o
Article history:
Received 29 October 2006
Received in revised form 5 February 2009
Accepted 11 February 2009
Keywords:
Motivational Interviewing
Diet
Exercise
Diabetes
Oral health
Dental health
Review
There is considerable evidence for the effectiveness of Motivational Interviewing (MI) in the treatment of
substance abuse, as well as a number of other health behavior areas. The present paper summarizes and
critically reviews the research in three emerging areas in which (MI) is being applied: diet and exercise,
diabetes, and oral health. Although 10prior reviews focused in part on MI studies in the areas of diet, exercise,or diabetes, the present paper provides an up-to-date review, and includes oral health as another emerging
area of MI research. Overall, 37 articles were reviewed: 24 in the areas of diet and exercise, 9 in the area of
diabetes, and 4 in the oral healtharea. Research in these areas suggests that (MI) is effective in allthese health
domains, although additional research is needed, particularly in the oral health arena. Specically, future
research in the areas of diet and exercise should examine the clinical utility of MI by health care professionals
(other than dietitians), studies in the area of diabetes should continue to examine long-term effects of MI on
glycemic control,and researchin theareaof oral healthshould focuson developingadditionaltrialsin this eld.
Further, future studies should demonstrate improved research methodology, and investigate the effects of
possible outcome mediators, such as client change talk, on behavior change.
Published by Elsevier Ltd.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
1.1. Description of Motivational Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
1.2. Past reviews and meta-analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
1.3. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
1.4. Critical review of MI in emerging health arenas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
1.4.1. Diet and exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
1.4.2. Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
1.4.3. Oral (dental) health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
1.4.4. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
2. Assessment of major issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
2.1. Training and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
2.2. Treatment integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
2.3. Treatment dose and delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
2.4. Other methodological issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
3. Conclusions and future research directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
1. Introduction
Motivational Interviewing (MI) has been applied to a number of
areas of behavioral change, and is best known for applications in the
realmof substance abuse.MI hasbeen utilized in several healtharenas
with promising results, for example, among individuals with HIV, to
reduce risky behaviors, and to reduce substance abuse and improve
HIV medication adherence (e.g., Parsons, Rosof, Punzalan, & Di Maria,
2005). This paper will provide a brief overview of MI and will evaluate
empirical studies testing the effectiveness and clinical utility of MI in
Clinical Psychology Review 29 (2009) 283–293
☆ This paper is based on a preliminary doctoral examination in the West Virginia
University Department of Psychology, submitted by the rst author and supervised by the
second author.☆☆ We would like to thank William Fremouw, Ph.D. for his involvement in the
preliminary examination process. Appreciation also is extended to colleagues in the
Anxiety, Psychophysiology, and Pain Research Laboratory in the Department of
Psychology at West Virginia University for their support of this project.
⁎ Corresponding authors. D.W. McNeil is to be contacted at Tel.: +1 304 293
2001x31622.
E-mail addresses: [email protected] (R.K. Martins),
[email protected] (D.W. McNeil).
0272-7358/$ – see front matter. Published by Elsevier Ltd.
doi:10.1016/j.cpr.2009.02.001
Contents lists available at ScienceDirect
Clinical Psychology Review
mailto:[email protected]:[email protected]://dx.doi.org/10.1016/j.cpr.2009.02.001http://www.sciencedirect.com/science/journal/02727358http://www.sciencedirect.com/science/journal/02727358http://dx.doi.org/10.1016/j.cpr.2009.02.001mailto:[email protected]:[email protected]
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three health areas: diet and exercise, diabetes, and oral health.
Further, suggestions to guide future research are provided.
1.1. Description of Motivational Interviewing
Miller and Rollnick (2002) dened MI as a client-centered, “di-
rective method for enhancing intrinsic motivation to change by ex-
ploring and resolving ambivalence” (p. 25). MI is a directive
psychosocial intervention used to identify and resolve discrepanciesbetween desired behaviors and actual behaviors, and to increase
motivation to facilitate behavior change (Miller & Rollnick, 2002).
Concepts such as reective listening are balanced with a directive
approach. The “spirit” (Miller & Rollnick, 2002; p. 34) of MI includes
principles of collaboration, evocation (of motivation from the client
herself), and client autonomy.
MI consists of two phases. During phase one, intrinsic motiva-
tion for change is enhanced whereas in phase two, commitment to
change is strengthened (Miller & Rollnick, 2002). The goal of MI is to
strengthen the importance of change from the patient's perspective
(Burke, Arkowitz, & Menchola, 2003), using four basic principles to
enhance motivation: (a) expression of empathy, (b) development of
discrepancy, (c) rolling with resistance, and (d) the support of self-
ef cacy (Miller & Rollnick, 2002). Discrepancy is developed between
desired behaviors and actual behaviors. The patient presents reasons
for change while the facilitator provides support. Alternately, if the
patient is resistant to change, the facilitator “rolls” with it instead of
ghting against it. If and when the patient is ready to initiate a change,
the facilitator supports that decision (Miller & Rollnick, 2002).
MI involves a client-centered approach to consultation. MI
adheres to the concept that behavior change is not the sole
responsibility of the patient, but is a shared endeavor. Practitioners
are in a unique position to either enhance the client's motivation to
change or to contribute to resistance (Rollnick, Mason, & Butler,
2002). Traditionally, in health care settings, recommendations for
behavior change are delivered through brief advice-giving in which
overt recommendations are provided (Hertiage & Se, 1992;
Rollnick et al., 2002). MI challenges traditional intervention
delivery methods by suggesting that patients know what is bestfor themselves, and that professionals should work with them to
determine what behavior change strategies will work best, while
acknowledging freedom of choice. A menu of choices is one way in
which recommendations can be given while maintaining the
patient's freedom of choice (Rollnick et al., 2002).
1.2. Past reviews and meta-analyses
Ten prior reviews, which have focused at least in part on diet,
exercise, or diabetes, have been published, and are presented
chronologically. A review of studies focused on MI in the oral health
arena has not been published. Each presented review includes studies
that met certain requirements of methodological rigor, individually
administered MI, and adaptations of MI in a variety of health areas.Brief MI interventions in the areas of substance abuse, smoking,
HIV risk behaviors, and diet and exercise were reviewed by Dunn,
DeRoo, and Rivara (2001). There were 29 studies reviewed that
delivered MI face-to-face, included MI monitoring, random assign-
ment, inclusion of a control group, and measurement of behavioral
and/orhealth outcomes. Dunn andcolleagues reported support forMI
in the areas of substance abuse, and diet and exercise, smoking
cessation and HIV risk reduction, with effect sizes (i.e., Hedge's g )
ranging from .23 to 2.17. Among the areas reviewed, diet and exercise
demonstrated the most signicant effects whereas the most modest
effects were found in the area of smoking cessation.
Burke, Arkowitz, and Dunn (2002) examined 26 studies in which
interventions based on MI principles were delivered individually and
face-to-face. The meta-analysis found small to moderate effect sizes
(i.e., d= .25 to .57) when MI was compared to no treatment or
treatment as usual for substance abuse, as well as diet and exercise;
support for MI for smoking cessation and reduction of HIV-risk
behaviors, however, was more modest.
Burke et al. (2003) conducted a meta-analysis of 30 controlled
clinical trials to examine the effectiveness of adaptations of MI (AMIs)
in the areas of alcohol abuse, smoking cessation, drug addiction, HIV-
risk behaviors, treatment adherence, and diet and exercise. Criteria for
inclusion in the meta-analysis included using an intervention basedon MI principles, and MI being delivered to an individual. AMIs were
determined to be as effective as other treatments, and more effective
than no-treatment or placebo controls, in the areas of alcohol, drugs,
and diet and exercise. As in the review the year before, however, there
was contradictory evidence in theareasof smoking cessationand HIV-
risk behaviors.
VanWormer and Boucher (2004) conducted a meta-analysis to
examine the effectiveness of MI in diet modication. Signicant
effects were found in three of the four reviewed studies. Importantly,
the review suggests that MI can be effective in small doses; however,
more frequent contact with patients can increase behavior change.
Burke, Dunn, and Atkins (2004) conducted a meta-analysis of 39
studies examining the effectiveness of AMIs in the areas of alcohol
problems, drug addiction, smoking cessation, HIV-risk behaviors, diet
and exercise, treatment compliance, eating disorders, asthma man-
agement, andinjury-risk behaviors. AMIs were found to be as effective
as other general interventions and yielded moderate effect sizes (i.e.,
d= .35 to .56) in areas such as substance abuse, as well as diet and
exercise.
Hettema, Steele, and Miller (2005) reviewed studies examining
the effectiveness of MI in the areas of alcohol, smoking, HIV/AIDS,
drug abuse, treatment compliance, gambling, intimate relationships,
water purication/safety, eating disorders, and diet and exercise.
There were 72 articles included in which a group or individual
intervention with components of MI was delivered, a posttreatment
outcome measure was included, a control or comparison group was
present, and a procedure to determine the pretreatment equivalence
of groups was utilized. Hettema, Steele and Miller (2005) reported a
range of effect sizes (i.e., g = .30 to .77) across MI studies, whichsuggest medium to large effects. Interestingly, effect sizes were found
to be higher when MI was used with Native Americans; however,
similar ndings were not found when MI was used with African
Americans or Hispanic Americans. Also, higher effect sizes were noted
when sessions were not guided by a manual.
Rubak, Sandbaek, Lauritzen, and Christensen (2005) performed a
meta-analysis to examine the effectiveness of MI across 72 rando-
mized, controlled studies in a variety of health areas, including diet
and exercise, diabetes, and substance abuse. A signicant effect of MI
was demonstratedin 74% of the studies reviewed. Among studies with
MI sessions that lasted 60 minutes, 81% showed an effect. Rubak,
Sandbaek, Lauritzen and Christensen (2005) suggest that the like-
lihood of an effect was positively correlated with the number of
encounters and with a prolonged follow-up period. Overall, MI wasfound to outperform traditional advice-giving in 75% of studies
reviewed. Of the studies that targeted diet and exercise, diabetes,
asthma, or smoking, 72% demonstrated an effect. Smoking studies
yielded an effect in 67% of those reviewed, whereas diabetes, asthma,
and diet and exercise studies reported an effect in 77% of the studies
reviewed (Rubak et al., 2005).
Knight, McGowan, Dickens, and Bundy (2006) discussed eight
studies in the elds of diabetes, asthma, hypertension, hyperlipidae-
mia, and heart disease in a systematic review of MI in physical health
care settings.Three studies were in the area of diabetes (e.g., Channon,
Smith, & Gregory, 2003), one in the area of asthma (e.g., Schmaling,
Blume, & Afari, 2001), one in the area of hypertension (e.g., Woolard
et al., 1995), one in the area of hyperlipidaemia (e.g., Mhurchú,
Margetts, & Speller, 1998), and two in the area of heart disease (e.g.,
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McHugh et al., 2001). Overall, the authors reported positive results for
the effects of MI on outcomes in the areas reviewed.
Resnicow, Davis, and Rollnick (2006) focused their review on
youth studies that used MI to modify diet or physical activity (e.g.,
Resnicow, et al., 2005), diabetes (e.g., Channon et al., 2003), and other
behaviors, such as smoking (e.g., Colby et al., 1998), and included
some adult studies that used MI to modify diet or physical activity
(e.g., Smith, Heckemeyer, Kratt, & Mason, 1997). The authors suggest
that although MI might be a feasible intervention to use with childrenand adolescents, additional studies with youth are needed in the areas
reviewed to determine the clinical utility of MI in the prevention or
treatment of pediatric obesity (Resnicow et al., 2006).
Most recently, Van Dorsten (2007) provided a summary of studies
examining the effectiveness of MI for weight loss and exercise. Results
of eight studies in the area of weight loss (e.g., Carels et al., 2007) and
two studies in the area of exercise (e.g., Harland et al., 1999) were
reported. The author concluded that MI was shown to signicantly
improve diet and exercise behaviors, regimen adherence, and weight
loss, based on the studies reviewed.
1.3. Summary
Across the 10 reviews, the use of MI was, in general, strongly
supported in affecting health behavior change and maintenance; MI
typically was more effective than no treatment andwhen compared to
traditional advice giving (Rubak et al., 2005). Nevertheless, several
limitations were identied through the reviews conducted to date.
Most commonly, studies have focused on adaptations of MI and noton
“pure” MI as an intervention (Burke et al., 2003). The duration of MI
sessions varied greatly. Additionally, high attrition rates have been
identied as a common threat to internal validity among studies
examining the effectiveness of MI (Burke et al., 2003). Attempts to
improve the internal validity of studies investigating MI have been
made by many authors, including efforts to ensure treatment delity
(e.g., Miller, Beneeld, & Tonigan, 1993; Project MATCH, 1997;
Stephens, Roffman, & Curtin, 2000). Overall, MI has among the
highest mean methodological quality in substance abuse treatment
outcome research (Miller & Wilbourne, 2002). Although not pre-sented in the current paper, several systematic reviews and meta-
analyses examining MI in a variety of other health areas, such as
substance abuse, have been published (e.g., Miller & Wilbourne, 2002;
Noonan & Moyers, 1997).
1.4. Critical review of MI in emerging health arenas
MI was rst developed as a method to help individuals decrease
alcohol and drug abuse and has been empirically supported for the
treatment of substance abuse. MI is a promising intervention to
encourage health behavior change in general, in a variety of settings,
alone or in conjunction with traditional interventions (Rollnick et al.,
2002). Existing MI research on promoting health behaviors, however,
has methodological limitations that must be addressed with futureresearch. The purpose of the present paper is to critically review
literature using MI to enhance the health care behaviors of patients in
three areas (i.e., diet and exercise, diabetes, and oral health), since
the rst published article on MI (Miller, 1983) through 2008. Articles
were acquired through a search of the MI website (www.motivatio-
nalinterviewing.org), through article and book reference lists, and
through database searches (e.g., Psych Info and Medline); search
keywords included the use of single terms (e.g., Motivational
Interviewing, motivation) and the use of a combination of descriptive
labels for each health area (e.g., Motivational Interviewing and
diabetes; motivation and diet).
This review is unique in that a comprehensive, critical, and focused
review of MI in the areas of diet and exercise, diabetes, and oral health
has not been conducted. Although MI studies of diet, exercise, and
diabetes have been examined in the literature, new studies have
appeared since the prior reviews were published. No review of studies
examining the effectiveness of MI in the area of oral health has yet
been published. These three health areas were selected because they
represent the growing empirical research examining the effectiveness
of MI to encourage positive health behaviors. There were 37 empirical
studies were reviewed: 24 in the areas of diet and exercise, 9 in the
area of diabetes, and 4 in the oral health area. Over time, the numbers
of MI studies across these three areas have increased, as evidenced bythe number of published empirical studies annually: 1997 — 1 article;
1998 — 1 article; 1999 — 2 articles, 2001 — 2 articles, 2002 — 1 article,
2003 — 4 articles, 2004 — 3 articles, 2005 — 3 articles, 2006 — 4
articles, 2007 — 10 articles, and 2008 — 6 articles.
1.4.1. Diet and exercise
Health care professionals are in a unique position to promote
dietary change and increased exercise in patients facing a variety of
health risks and issues through imparting information, skills training,
and fostering motivation. Although diet and exercise are discussed
here as a separate topic, both play an important role in other health
areas, including obesity, diabetes, and oral health. These two health
areas of health behavior, while related in terms of impact on outcomes
(e.g., body mass index [BMI]), maybe distinct in terms of howMI (and
other interventions) can positively impact change or maintenance.
There have been 24 published empirical articles identied as utilizing
MI as an intervention to modify diet and/or exercise behaviors. A
summary of the empirical articles utilizing MI in the areas of diet and
exercise is provided in Table 1. Overall, studies support the effective-
ness of MI in the areas of diet and exercise (e.g., Berg-Smith et al.,
1999; Bowen et al., 2002; Harland et al., 1999; Resnicow et al., 2000,
2001; Smith et al., 1997), both alone, and in combination with other
interventions. Specically, patients who received MI reported in-
creased self-ef cacy related to diet and exercise (e.g., Bennett et al.,
2008; Resnicow et al., 2004), increased physical activity (e.g., Bennett
et al., 2007; Carels et al., 2007; Harland et al., 1999; Hardcastle et al.,
2008), reduced caloric intake (e.g., Befort et al., 2008), and increased
fruit and vegetable consumption (e.g., Ahluwalia et al., 2007; Befort et
al., 2008; Elliot et al., 2007; Hardcastle et al., 2008; Resnicow et al.,2000, 2001, 2004, 2005; Richards, Kattelmann, & Ren, 2006). Further,
patients who received MI demonstrated decreased BMI (e.g., Hard-
castle et al., 2008; Schwartz et al., 2007) after the intervention.
Although MI was not always found to be more effective than other
treatments, overall the ndings support the clinical utility of MI in
these areas.
1.4.2. Diabetes
The management of diabetes requires lifelong patient adherence to
behaviors associated with diet restrictions, medication treatment,
regular medical consultations, exercise regimens, restricted alcohol
consumption, and smoking cessation (Clark & Hampson, 2001; Stott,
Rees, Rollnick, Pill, & Hackett, 1996). Patients vary in their readiness
and willingness to make recommended changes or to develop alifestyle consistent with these stipulations, but most present with
some degree of ambivalence about change (Rollnick, Kinnersley, &
Stott, 1993).
Table 2 shows a summary of nine published empirical studies
examining the use of MI in either Type 1 or Type 2 diabetes
management. Participants in ve studies were diagnosed with Type
1 diabetes (i.e., Channon et al., 2003, 2007; Ismail et al., 2008; Knight
et al., 2003; Viner et al., 2003), whereas four studies focused on
individuals with Type 2 diabetes (i.e., Brug et al., 2007; Clark &
Hampson, 2001; Smith et al., 1997; Smith-West et al., 2007). Lifestyle
changes (e.g., diet and exercise) were the focus of MI, regardless of
type of diabetes. Studies examining the use of MI (e.g., Channon et al.,
2003) or MI in combination with other interventions (e.g., Smith et al.,
1997) provided evidence for the effectiveness of MI in this health area.
288 R.K. Martins, D.W. McNeil / Clinical Psychology Review 29 (2009) 283– 293
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MI was found to be effective in assisting patients control glucose
levels (e.g., Channon et al., 2003, 2007; Smith et al., 1997; Viner et al.,
2003; Smith-West et al., 2007), increase physical activity (e.g., Smith-
West et al., 2007), decrease weight (e.g., Smith et al., 1997; Smith-
West et al., 2007), and engage in dietary changes (e.g., Brug et al.,
2007; Clark & Hampson, 2001), both alone and in combination with
other interventions. Further, MI appeared to contribute to additional
successes, such as increased self-ef cacy (e.g., Viner et al., 2003) and
increased sense of control over diabetes (e.g., Knight et al., 2003).
1.4.3. Oral (dental) health
In recent years, oral health problems have been associated with a
variety of systemic health issues, such as diabetes ( Jansson, Lindholm,
Lindh, Groop, & Bratthall, 2006), cardiovascular disease (Beck &
Offenbacher, 2005; Genco, Offenbacher, & Beck, 2002), low birth
weight ( Jeffcoat, Guers, Reddy, Goldenberg, & Hauth, 2001), pre-
mature birth ( Jeffcoat, Guers, Reddy, Cliver et al., 2001; Offenbacher
et al., 2006), and respiratory illness (Mojon, 2002). Engaging in
appropriate oral health care not only can prevent many dental
problems but also may impact other systemic health issues, such as
diabetes, heart and lung disease, and stroke (Peterson, 2003).
Although MI is relatively new to oral health, it seems to be a
promising method to improve oral health status, based on four
available articles on caries prevention or attendance at dental
appointments. Table 3 provides a summary of these published
empirical studies. There is other important work in the oral health
arena that focuses on health behaviors not included in the present
review, including tobacco and alcohol use. MI has shown promise in
preserving the oral health of infants and other children, with the
intervention targeted at their mothers (e.g., Harrison et al., 2007;
Weinstein et al., 2004, 2006) (or perhaps their fathers, or other
caregivers). MI also seems to have potential to address the self-care of
adolescents and adults, with particular applications to special
populations (e.g., pregnant women) whose oral health status may
be related to other health outcomes (e.g., length of pregnancy). Delay
or avoidance of timely dental care is an important area that MI
ultimately may help to address, although the present data are quite
preliminary(e.g., Skaret et al., 2003). With only four studies publishedin this area, the eld invites further work.
1.4.4. Summary
There were 37 published empirical articles in the areas of diet and
exercise, diabetes, and oral health that were reviewed. Each of the
studies reviewed focused on health-related behaviors that require life-
long adherence in order to achieve maximum health benets. For
example, consistent glycemic control is essential in the treatment of
diabetes to ensure the best possible outcomes. As such, after behavior
change is achieved, the focus shifts to maintenance of these behaviors.
Individuals who received MI showed signicant behavior changes with
important implications for their health across the areas of diet and
exercise, diabetes, and oral health, more often than not. In many cases,
behavior changes were maintained over a long period of time (e.g., oneor two years); however, follow-up data beyond two years in these areas
were not available, but should be a focus of future research.
2. Assessment of major issues
Development and implementation of MI, a treatment vehicle
through which information, motivation, and recommendations can be
provided to patients, has immense clinical implications. MI been
shown to be effective in a number of health areas, including diet and
exercise, diabetes management, and oral health; however, several
methodological concerns require additional focus in order to more
condently demonstrate the effectiveness of MI. Specically, training
and practice issues, treatment integrity issues, treatment dose and
delivery, and other methodological issues are discussed. T
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r a t e ) a t f o l l o
w - u p t h a n c h i l d r e n w i t h
m o t h e r s i n t h e c o n t r o l g r o u p .
W
e i n s t e i n , H a r r i s o n ,
a n d B e n t o n ( 2 0 0 6 )
2 4 0
S o u t h A s i a n P u n j a b
i -
s p e a k i n g m o t h e r s w
i t h
h e a l t h y i n f a n t s a g e d 6 t o
1 8 m o n t h s
M o t i v a t i o n a l i n t e r v i e w i n g
( 1 2 2 ) , C o n t r o l / h e a l t h
e d u c a t i o n ( 1 1 8 )
P a m p h l e t ; v i e w e d 1 1 - m i n u t e
e d u c a t i o n a l v i d e o ,
“ P r e v e n t i n g
t o o t h d e c a y
f o r i n f a n t s a n d
t o d d l e r s ”
O n e 4 5 - m i n u t e
s e s s i o n , 6
f o l l o w - u p
t e l e p h o n e c a l l s , 2
p o s t c a r d s
B i w e e k l y s u p e r v i s i o n
a n d r e v i e w o f s e l e c t
s e s s i o n
a u d i o t a p e s
1 5 %
2 y e a r s
C h i l d r e n w i t h m o t h e r s i n t h e M I g r o u p
e x p e r i e n c e d
s i g n i c a n t l y f e w e r n e w c a v i t i e s
a n d o b t a i n e d s i g n i c a n t m o r e u o r i d e
v a r n i s h a p p l i c a t i o n s t h a n c h i l d r e n w i t h
m o t h e r s i n t h e c o n t r o l g r o u p .
W
e i n s t e i n , H a r r i s o n ,
a n d B e n t o n ( 2 0 0 4 )
2 4 0
S o u t h A s i a n P u n j a b
i -
s p e a k i n g m o t h e r s w
i t h
h e a l t h y i n f a n t s a g e d 6 t o
1 8 m o n t h s
M o t i v a t i o n a l i n t e r v i e w i n g
( 1 2 2 ) , C o n t r o l / h e a l t h
e d u c a t i o n ( 1 1 8 )
P a m p h l e t ; v i e w e d 1 1 - m i n u t e
e d u c a t i o n a l v i d e o ,
“ P r e v e n t i n g
t o o t h d e c a y
f o r i n f a n t s a n d
t o d d l e r s ”
O n e 4 5 - m i n u t e
s e s s i o n a n d 6
f o l l o w - u p t e l e p h o n e
c a l l s , 2 p o s t c a r d s
A u d i o t a p e s w e r e
p e r i o d i c
a l l y r e v i e w e d
t o e n s u r e c o n s i s t e n t
M I d e l i v
e r y
N / A
2 , 4 ,
6 w e e k s ;
6 m o n t h s ;
1 y e a r
C h i l d r e n w i t h m o t h e r s i n t h e M I g r o u p h a d
f e w e r c a v i t i e s t h a n c h i l d r e n i n t h e c o n t r o l
g r o u p .
S
k a r e t , W e i n s t e i n , K v a l e ,
a n d R a a d a l ( 2 0 0 3 )
5 0
1 8 - y e a r - o l d a d o l e s c
e n t s
w i t h a h i s t o r y o f d e n t a l
a p p o i n t m e n t a v o i d a n c e
R e s p o n s e c a r d s ( 1 3 ) ,
M o t i v a t i o n a l i n t e r v i e w i n g
( 1 2 ) , C o m b i n e d R C + M I ( 1 2 ) ,
C o n t r o l / h e a l t h e d u c a t i o n ( 1 3 )
N o n e
O n e b r i e f , s
t r u c t u r e d
t e l e p h o n e
i n t e r v i e w a
b a s e d o n
M I a p p r o a c h
N / A
3 6 %
N / A
A d o l e s c e n t s
w h o r e c e i v e d t h e t h r e e
i n t e r v e n t i o n
s v i e w e d t h e i n t e r v e n t i o n s a s
c r e d i b l e .
N
o t e .
N / A , I n f o r m a t i o n n o t a v a i l a b l e .
a
L e n g t h o f s e s s i o n w a s n o t r e p o r t e d .
290 R.K. Martins, D.W. McNeil / Clinical Psychology Review 29 (2009) 283– 293
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2.1. Training and practice
To deliver MI appropriately, training and practice are essential.
Training procedures utilized in the studies reviewed here typically
were rarely or insuf ciently identied and described (Burke et al.,
2003). Further, MI training can vary in factors such as length of
training and training methods, perhaps resulting in variability of skill
acquisition (Madson, Loigon, & Lane, 2009). Trainingalone maynot be
suf
cient for the absorption and integration of motivational skills(Berg-Smith et al., 1999). Although increases in MI prociency often
were noted after training workshops (e.g., Miller, Yahne, Moyers,
Martinez, & Pirritano, 2004), a tendency to return to baseline over
time, with no additional training, feedback, or coaching, has been
observed (Miller & Mount, 2001). Ongoing practice and feedback are
needed to fully learn and maintain skills (Miller & Rollnick, 2002). In
fact, eight stages in learning MI were identied by Miller and Moyers
(2006), suggesting that learning MI begins with understanding MI
spirit and ultimately results in the integration of MI with other
theoretical approaches through continued education and practice.
Future studies should focus and report on improved MI training and
ongoing practice with coaching (Miller et al., 2004).
2.2. Treatment integrity
Despite the availability of useful, validated treatment integrity
tools, many studies fail to assesstreatment integrity over the courseof
the intervention, or they fail to report this assessment. In recent years,
two behavioral coding systems have been developed and are widely
used to address the need to assess treatment integrity in the delivery
of MI, and as a learning tool in MI training. For a review of other
delity measures that are available see Madson and Campbell (2006).
The Motivational Interviewing Skill Code (MISC) 1.0 was developed in
1997 to assess the quality of MI utilized by identifying active
components (e.g., reections) of MI(Miller, Moyers, Ernst, & Amrhein,
2003). The latest version of this coding system, MISC 2.1, was released
in 2008 to “improve on earlier versions of the MISC in reliability,
ef ciency, and relevance to training and clinical practice” (Miller,
Moyers, Ernst, & Amrhein, 2008; p. 1). Entire lmed or audiotapedrecordings and transcripts are coded using MISC 2.1 in three passes.
The rst pass provides clinician global ratings on the dimensions of
acceptance, empathy, and MI spirit and a client global rating based on
self-exploration on a 7-point Likert scale (Miller et al., 2008; Moyers,
Martin, Catley, Harris, & Ahluwalia, 2003). The second pass provides
clinician behavior codes using 15 major categories of behavior (e.g.,
advise, af rm, confront, direct). The third pass provides client
behavior codes using eight content codes (e.g., reasons, taking steps,
commitment). More experienced coders may wish to combine the
second and third passes (Miller et al., 2008).
The Motivational Interviewing Treatment Integrity (MITI) code
Version 2.0 was developed by Moyers, Martin, Manuel, Hendrickson,
and Miller (2005) to assess10 elements of MI. MITI is considered to be
simpler than MISC as a tool to assess treatment integrity and providefeedback. Whereas MISC examines both the clinician and client
behaviors and the interaction between the two, MITI focuses only on
the behavior of the clinician. Further, MITI consists of only one pass
through session tapes, reducing the time and cost required to code
tapes (Moyers, Martin et al., 2005), but again, only provides
information about the clinician. Whereas, coders using MISC 2.1
code the entire session, coders using MITI 3.0 code a randomly
selected 20-minute portion of the recording. In the most recent
version of the MITI (3.0), coders provide global scores on a 5-point
Likert scale characterizing the interaction based on Evocation,
Collaboration, Autonomy/Support, Direction, and Empathy. Particular
behaviors, such as giving information, questions, reections, and
behaviors that are consistent (e.g., supporting the client) and that are
not consistent with MI (e.g., confronting) are counted (Moyers,
Martin, Manuel, Miller, & Ernst, 2007). Although both MISC and MITI
can provide treatment integrity information and feedback related to
clinicians' implementation of MI, use of MISC may be most appro-
priate in verifying the effectiveness and clinical utility of MI in the
three research arenas discussed in this review (and others). MITI may
be more ef cient if treatment outcome is not the focus of coding.
2.3. Treatment dose and delivery
Miller and Rollnick (2002) propose that dose of counseling is
related to behavior change or outcome; however, motivation for
change also plays a role. Previous reviews have suggested that length
and number of MI sessions are associated with behavior change, such
that among studies with two MI sessions and at least 60 minutes of
contact perencounter,81% showed an effect(Burke et al., 2003; Rubak
et al., 2005). Additional study, however, is neededin this area, as some
studies demonstrate signicant behavior change after relatively few
MI sessions, whereas others fail to demonstrate signicant behavior
change after many MI sessions. For example, Bennett et al. (2007)
reported a signicant increase in physical activities after one 30-
minute MI session and two follow-up phone calls whereas partici-
pants who received three MI sessions in the Mhurchú et al. (1998)
study did not demonstrate signicant changes in total and saturated
fat intake, or energy intake from fat compared to the control group.
Thetype of dependentvariable, of course, is an importantfactor which
may impact whether andwhen change canbe evidenced. Although MI
dose may be an important factor in treatment outcome, many studies
fail to report length of MI sessions. Further, a description of session
content rarely is provided.
2.4. Other methodological issues
Other general methodological concerns include lack of power,
small sample sizes, mixed intervention groups, and lack of treatment
control groups among some of the studies reviewed here. Several
studies lacked adequate power to identify differences between
groups, related to small sample sizes. Further, combining MI with
other interventions, while perhaps wise clinically (e.g., MI and aweight loss program), makes it impossible to determine the unique
contributions of MI on behavior change. Similarly, without the
inclusion of appropriate control groups, the unique effects of MI
cannot be determined. Such concerns have been reported in other
reviews (e.g., Knight et al., 2006), and have been addressed in more
recent MI studies in the areas discussed in this review.
3. Conclusions and future research directions
MI is a promising intervention to encourage positive health
behavior change in medical and dental settings (Resnicow et al.,
2002), as noted in the studies presented here. Specically, MI may
help individuals improve their oral health, and may enhance
adherence to diet and exercise modication programs, and diabetesmanagement. MI has been found to be more effective than no
treatment, and in many cases, more effective than other active
treatments (Burke et al., 2003). MI also may be more cost-effective
than other treatments, adding to its applicability potential (Burke et
al., 2003; Knight et al., 2003).Further, MIcan beutilized bya variety of
health care professionals (e.g., physicians, dentists, nurses, dieticians)
and applied in a variety of settings (e.g., churches, medical centers) to
inuence a variety of health behaviors. Because MI can be delivered in
a relatively short time, health professionals can incorporate it into
clinical practice or apply it in time-sensitive situations. Finally,
acceptability of MI among patients is very high, allowing health care
professionals to work with their patients to improve their health. In all
three health areas reviewed here, health care providers may be prone
to give advice and to be confrontational with their patients. In these
291R.K. Martins, D.W. McNeil / Clinical Psychology Review 29 (2009) 283– 293
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areas (and others), MI provides a “kinder and gentler,” respectful, and
perhaps more ef cacious approach that is less likely to produce
resistance among patients.
Although many of the studies conducted to date in the three areas
reviewed in this paper have several limitations, MI still seems clearly
indicated for a variety of health behavior arenas beyond addictions.
Importantly, recent studies have been more methodologically sophis-
ticated. Future research should continue to focus on designing studies
that have improved methodology including assuring adequate power,preventing or at least measuring attrition, providing improved
training to interventionists, and ensuring treatment integrity, in
addition to improving overall study design. Diet and exercise has
commanded greater research focus relative to the other two areas.
Clearly, more research is needed with a breadth of populations to
contribute to the research base of MI in oral health care. Finally,
although MI is being rapidly applied to a variety of settings, several
important questions remain to be answered. What are the active
ingredients in MI? What processes mediate the outcome of MI? How
much does client language predict outcome (e.g., Amrhein, Miller,
Yahne, Palmer, & Fulcher, 2003; Moyers, Martin, Christopher et al.,
2007)? How do therapist characteristics affect client behavior (e.g.,
Moyers, Miller, & Hendrickson, 2005)? What is the acceptability and
effectiveness of MI among ethnic and racial minorities? Through a
programmatic research effort, the effectiveness and clinical utility of
MI in these three areas, and other health arenas, can be further
developed.
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